Fracturing calcifications in heart valves

ABSTRACT

A method for heart valve treatment includes providing a first heart valve treatment member movable along a first shaft portion, providing a second heart valve treatment member movable along a second shaft portion. The first and second heart valve treatment members are movable along the first and second shaft portions, respectively. The first heart valve treatment member is positioned on one side of a heart valve leaflet and the second heart valve treatment member is positioned on an opposite side of the heart valve leaflet. A portion of the heart valve leaflet is fracture by movement of the first heart valve treatment member with respect to the second heart valve treatment member.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. Pat. Application 17/464890,filed Sep. 2, 2021, now U.S. Pat. 11690637, which is a continuation ofU.S. Pat. Application 15/418919, filed Jan. 30, 2017, which is acontinuation of U.S. Pat. Application 13/514090, filed Jun. 5, 2012, nowU.S. Pat. 9554816, which is a national stage filing ofPCT/US2010/055810, filed Dec. 3, 2010, which claims priority to U.S.Provisional Pat. Applications 61/356617, filed Jun. 20, 2010, and61/267029, filed Dec. 5, 2009, the entire contents of each of which areincorporated herein by reference.

FIELD OF THE INVENTION

The present invention generally relates to devices and methods forfracturing calcifications in heart valves, such as aortic valveleaflets.

BACKGROUND OF THE INVENTION

Essential to normal heart function are four heart valves, which allowblood to pass through the four chambers of the heart in the proper flowdirections. The valves have either two or three cusps, flaps, orleaflets, which comprise fibrous tissue that attaches to the walls ofthe heart. The cusps open when the blood flow is flowing correctly andthen close to form a tight seal to prevent backflow.

The four chambers are known as the right and left atria (upper chambers)and right and left ventricles (lower chambers). The four valves thatcontrol blood flow are known as the tricuspid, mitral, pulmonary, andaortic valves. In a normally functioning heart, the tricuspid valveallows one-way flow of deoxygenated blood from the right upper chamber(right atrium) to the right lower chamber (right ventricle). When theright ventricle contracts, the pulmonary valve allows blood to flow fromthe right ventricle to the pulmonary artery, which carries thedeoxygenated blood to the lungs. The mitral valve, allows oxygenatedblood, which has returned to the left upper chamber (left atrium), toflow to the left lower chamber (left ventricle). When the left ventriclecontracts, the oxygenated blood is pumped through the aortic valve tothe aorta.

Certain heart abnormalities result from heart valve defects, such as isstenosis or calcification. This involves calcium buildup in the valvewhich impedes proper valve leaflet movement.

SUMMARY OF THE INVENTION

The present invention seeks to provide improved devices and methods thatmay be used for fracturing calcifications in aortic valve leaflets, inorder to increase leaflet pliability and mobility, either as stand alonetreatment, bridge treatment or preparation of the “landing zone” fortrans-catheter valve implantation.

The term “fracture” refers to any kind of reduction in size or anymodification in shape or form, such as but not limited to, fracturing,pulverizing, breaking, grinding, chopping and the like.

There is provided in accordance with an embodiment of the invention adevice for fracturing calcifications in heart valves including acatheter including an external shaft in which are disposed an expandablestabilizer, an impactor shaft on which are mounted expandable impactorarms, and an internal shaft, characterised in that the internal shaft ismovable to cause the impactor arms to expand outwards and be locked inan expanded shape, and wherein an impacting element is movable to causethe impactor arms, while in the expanded shape, to move towards thetissue with sufficient energy so as to fracture a calcification locatedin tissue which is fixed by the stabilizer in a certain positionvis-à-vis the impactor arms.

In accordance with a non-limiting embodiment of the invention theimpacting element includes the internal shaft which is connected to adistal portion of the impactor arms and which is operative to moverelative to the impactor shaft to expand the impactor arms outwards andto cause the impactor arms, while in the expanded shape, to move towardsthe stabilizer with the sufficient energy. The internal shaft may belockable relative to the impactor shaft so that the impactor arms arefixed.

In accordance with a non-limiting embodiment of the invention theimpacting element includes a weight and a biasing device, wherein thebiasing device urges the weight towards the impactor arms with thesufficient energy. In one example, the weight is mounted on the biasingdevice which is fixed to a distal tip of the catheter. In anotherexample, the weight is fixed to the internal shaft of the catheter. Inyet another example, the biasing device includes a pneumatic energysource connected to a pressurized air source.

In accordance with a non-limiting embodiment of the invention thestabilizer includes a stabilizer structure that includes one or moreelements (of any form or shape, such as rods, loops or more complexstructures) optionally covered by a stabilizer cover. The stabilizer mayinclude a stabilizer structure covered by a covering balloon. Aninflate/deflate tube may be inserted into the covering balloon. A firstpressure sensor may be located near the stabilizer (in the portion ofthe catheter that lies in the aorta) and a second pressure sensor may belocated near the impactor arms (in the portion of the catheter that liesin the LVOT or left ventricle). The device can be designed in a“reverse” manner for trans-apical use, so that the impactor is proximaland the stabilizer may be positioned at a distal tip of the device.Stabilizer arms may be expandable outwards from the external shaft.

BRIEF DESCRIPTION OF THE DRAWINGS

The present invention will be understood and appreciated more fully fromthe following detailed description, taken in conjunction with thedrawings in which:

FIG. 1 is a simplified illustration of the anatomy of a calcified aorticvalve, ascending aorta and aortic arch.

FIG. 2 is an enlarged view of a calcified aortic valve.

FIG. 3 is a simplified illustration of a distal part of an impactorcatheter system that can be used for fracturing aortic valvecalcifications, constructed and operative in accordance with anon-limiting embodiment of the invention.

FIG. 4 is a simplified illustration of several shafts that come out atthe proximal side of the catheter of FIG. 3 .

FIG. 5 is a simplified illustration of a device for fracturingcalcifications in heart valves, in accordance with another non-limitingembodiment of the present invention, employing a weight.

FIGS. 5A and 5B are simplified illustrations of the weight before andafter impact, respectively.

FIGS. 6 and 6A are simplified illustrations of a device for fracturingcalcifications in heart valves with a weight, in accordance with yetanother non-limiting embodiment of the present invention.

FIG. 7-10C are simplified illustrations of several types of stabilizers,in accordance with different non-limiting embodiments of the presentinvention, which can be used to effectively position the distal portionof the device, hold a portion of the leaflets in place during impact andto counteract the impact applied to the ventricular aspect of the valveleaflets.

FIG. 11 is a simplified illustration of impactor arms having more thanone arm facing each leaflet, in accordance with a non-limitingembodiment of the present invention.

FIG. 12 is a simplified illustration of an impactor catheter, inaccordance with a non-limiting embodiment of the present invention,which optimally maintains valve function during the procedure whileallowing continuous measurement of the blood pressure gradient betweenthe left ventricle and the aorta.

FIG. 13 is a simplified illustration of a trans-apical configuration ofa device that delivers impact to the calcified valve leaflets, inaccordance with a non-limiting embodiment of the invention.

FIG. 14 and FIG. 15 are simplified illustrations of an impactor catheterbased on a pneumatic energy source on the proximal side of the catheterand a weight-pull impact mechanism on the distal portion, in accordancewith a non-limiting embodiment of the invention.

FIGS. 16A-16D are simplified illustrations of an impactor device,constructed and operative in accordance with another non-limitingembodiment of the present invention.

FIG. 17 is a simplified illustration of the distal end of the device ofFIGS. 16A-16D, showing locating and vibratory elements in their openpositions.

FIGS. 18A and 18B are simplified illustrations of a diseased tricuspidheart valve with diseased leaflets having calcified lesions.

FIGS. 19A-19I are simplified illustrations of a method of using thedevice of FIGS. 16A-16D, in accordance with another non-limitingembodiment of the present invention.

FIG. 20 is a simplified illustration of the locating elements of thedevice having a mesh connected to them so as to capture any debris thatmay be created as part of the process.

FIGS. 21A and 21B are simplified illustrations of another embodimentwherein the locating elements are inflatable cushions or balloons.

FIG. 22A illustrates a longitudinal cut through the aortic wall withfracture lines created at the centerline of the leaflet by an impactor.

FIG. 22B is an x-ray of a typical leaflet after a single fracture wascreated close to its centerline.

DETAILED DESCRIPTION OF EMBODIMENTS

Reference is now made to FIG. 1 , which illustrates the anatomy of acalcified aortic valve, ascending aorta and aortic arch. Calcificationsmay be embedded in the valve leaflets, which are connected to the aorticwall just below the coronary ostia.

Reference is now made to FIG. 2 , which is an enlarged view of acalcified aortic valve. The leaflets create concave sinuses on theiraortic aspect, just below the coronary ostia. Calcification can beembedded in the leaflets, making the leaflets thicker and less pliable.Specifically, calcification that occurs at the leaflet base, i.e., wherethe leaflet connects to the annulus or aortic wall, can significantlyimpair the mobility of the leaflet, similar to friction in a door-hinge.

Reference is now made to FIG. 3 , which illustrates a distal part of animpactor catheter system that can be used for fracturing aortic valvecalcifications, constructed and operative in accordance with anon-limiting embodiment of the invention.

A catheter 10 may be delivered over a guide-wire 11 through a vessel,such as the peripheral artery, using a retrograde approach, through theaortic arch and into the ascending aorta, just above the aortic valve.At this stage, all catheter components are still covered by a catheterexternal shaft 12. The external shaft 12 is then retracted so that anexpandable (e.g., self-expanding) stabilizer 14, connected to astabilizer shaft 16, opens up. Stabilizer 14 is used to guide, positionand anchor the catheter distal part in the sinuses, just above the valveleaflets. It is noted that catheter 10 is just one example of a deliverysystem used to deliver and manipulate a stabilizer and impactor armsdescribed below to impact calcifications. Optionally, the stabilizer andimpactor arms described below may be delivered and/or manipulated byother devices other than a catheter, such as a guidewire or system ofguidewires and push/pull wires.

An impactor shaft 18, including impactor arms 20, is then pushed forward(distally) through the center of the valve into the left ventricle. Whenpushed forward the impactor arms 20 are folded so that they can easilycross the valve. An internal shaft 22, which is connected to the distalportion of the impactor arms 20, is then pulled proximally to cause theimpactor arms 20 to open (expand) outwards sideways and lock them in theexpanded shape. Impactor and internal shafts 18 and 22 are then pulledback (proximally) a bit in order for the impactor arms 20 to make goodcontact with the ventricular aspect of the leaflets, so that theleaflets are “sandwiched” between the proximally-located stabilizer 14(from above in the sense of the drawing) and the distally-locatedimpactor arms 20 (from below in the sense of the drawing). In order tofracture leaflet calcifications, impactor arms 20 are pulled abruptlytowards the leaflet tissue, while the stabilizer 14 holds the relevantportion of the leaflets in place, by pulling impactor and internalshafts 18 and 22 at a speed of at least 1 m/sec, such as withoutlimitation, around 5-20 m/sec, but with an amplitude of at least 0.5 mm,such as without limitation, about 0.5-3 mm, so that calcification isfractured but soft tissue is unharmed.

Reference is now made to FIG. 4 , which illustrates the several shaftsthat come out at the proximal side of the catheter 10 shown in FIG. 3 .The entire manipulation of catheter 10 is done by controlling therelative positions of these shafts. For example, as shown in FIG. 3 ,the internal shaft 22 is pulled relative to impactor shaft 18 in orderto open up impactor arms 20. The internal shaft 22 and the impactorshaft 18 are locked together so that the impactor arms 20 are fixed. Foreffective impact to be produced at the distal portion of the catheter,the internal/impactor shafts 22/18 are pulled together abruptly relativeto the valve leaflet tissue while stabilizer shaft 16 is fixed. Theabrupt pull at the proximal side is conveyed to the distal part.

Reference is now made to FIG. 5 , which illustrates an alternativemechanism for generating impact at the distal part of the catheter. Aweight 24 is mounted on a biasing device 26 (e.g., a coil spring) thatis fixed to a distal tip 28 of the catheter. Before impact (FIG. 5A),weight 24 is pushed towards distal tip 28 so that biasing device 26 iscontracted. In order to generate impact, weight 24 is released so thatbiasing device 26 is allowed to accelerate the weight 24 until it hitsthe impactor arms 20 (FIG. 5B). The impactor arms 20 in turn impact thecalcified leaflets. In order to maximize the impact velocity of theimpactor arms 20 given a certain momentum of the accelerated weight 24,the mass of the impactor arms 20 may be diminished. This can be partlyachieved by selecting an impactor shaft 18 that is also spring-like,minimizing the pushability of the impactor shaft 18, or by making theimpactor arms 20 “floating” and free to move with no friction withrespect to the other parts of the catheter during impact

Reference is now made to FIG. 6 , which illustrates yet anotheralternative mechanism for generating impact at the distal portion of thecatheter. A weight 24A (can be the catheter tip) is fixed to theinternal shaft 22 of the catheter (in this configuration the impactorarms 20 are not connected to the internal shaft 22). Before impact theinternal shaft 22 is pushed distally so that the weight 24A moves acertain distance (can be a few mm to several centimeters) away from theimpactor arms 20. In order to generate impact, the weight 24A is nowaccelerated proximally until it hits the impactor arms 20 with highvelocity. A biasing device 26A (one version of which is illustrated inFIG. 6A), a pneumatic mechanism, or any other mechanism can be used inorder to generate the required acceleration of the mass. The advantageof this method over the method described in FIGS. 3-4 is that when theenergy source is external, it may be easier to generate high velocitiesat the distal portion of the catheter by using more powerful biasingdevices or energy sources.

Reference is now made to FIGS. 7-10 , which illustrate several types ofstabilizers, which can be used to effectively position the distalportion of the catheter relative to the valve anatomy, hold certainportions of the valve leaflets in place during impact and alsocounteract the impact applied to the ventricular aspect of the valveleaflets. Ideally one would like to maximize the counteract force on theaortic aspect of the leaflets during impact while making sure thestabilizer surface is sufficiently compliant and blunt so to minimizeinjury to the leaflet surface.

Reference is now made to FIG. 7 , which illustrates an stabilizerstructure 30 that can take the form of one or more loops (e.g., at leastone loop fits into each of the sinuses above the leaflets, two or morefor bicuspid aortic valves and three or more for tricuspid aorticvalves). The stabilizer structure 30 is (optionally) covered by astabilizer cover 32, which can be a thin metal mesh (net), a solidplastic surface, etc. If the stabilizer cover 32 is solid, or if it isbased on a net with pores that are small enough, then the stabilizercover 32 can be used as an embolic protection means, i.e., at the end ofthe impact procedure, if any emboli have been generated, then they canbe safely collected into the catheter when folding back the stabilizerusing the external shaft.

Reference is now made to FIG. 8 , which illustrates an alternativestabilizer design, which incorporates a covering balloon 34 on eachstabilizer structure 30. Each balloon 34 is elongated and its centralaxis follows the curvature of the loops that make up the stabilizerstructure 30. The loops can also be used as inflate/deflate tubes forthe balloons, with fluid for the inflation passing through one or moreinflation/deflation openings 36. The great advantage of theballoon-based stabilizer is that the stabilizer can be positioned in thesinuses with the balloons deflated. Then the balloons 34 can be inflatedto generate full contact with the leaflets surface, maximizing theimpact counteract force, while avoiding injury.

Reference is now made to FIG. 9 , which illustrates yet another designof a balloon-based stabilizer. Each of the three covering balloons 34covers one of the stabilizer structure loops 30. An inflate/deflate tube38 can be inserted into each balloon on its proximal side. FIG. 10Aillustrates balloon 34 as viewed from above. FIGS. 10B and 10Cillustrate balloon 34 from the side, respectively deflated and inflated.

Reference is now made to FIG. 11 , which illustrates anotherconfiguration of impactor arms 20, which comprises more than one armfacing each leaflet. It may be readily understood that the number andgeometry of the impactor arms are based on the optimal locations whereone wishes to impact the leaflets, e.g., number and orientation ofimpact lines, points or regions per leaflet, impact closer to leafletbase or tip, etc.

Reference is now made to FIG. 12 , which illustrates a configuration ofthe impactor catheter, which optimally maintains valve function duringthe procedure while allowing continuous measurement of the bloodpressure gradient between the left ventricle and the aorta. The impactorarms 20 and stabilizer structure 30 contact the leaflets only at theirbases, i.e. near the annulus, where heavily calcified leaflets aretypically immobile. The leaflet tips remain free to move, so thatoverall valve function is almost undisturbed by the device when itdelivers impact. Two pressure sensors, a first pressure sensor 40 abovethe valve (near the stabilizer) and a second pressure sensor 42 belowthe valve (near the impactor arms) measure the aortic and ventricularblood pressures, respectively. This allows continuous measurement of thepressure gradient across the valve, which can be used as a veryimportant real time feedback for the success of the procedure.Alternatively to incorporating pressure sensors in the device, one candesign sufficiently large conduits in the catheter having a distalopening at each region of interest where pressure needs to be measuredand a proximal port that can be connected to a pressure sensor outsidethe patient body.

Reference is now made to FIG. 13 , which illustrates a trans-apicalconfiguration of a device that delivers impact to the calcified valveleaflets. Similar elements are similarly designated as above. Thetrans-apical approach, while being more invasive than the trans-femoralapproach, allows the device to be rigid and short, thereby potentiallyimproving the delivery of impact from the proximal (external) portion ofthe device to the impactor arms on its distal portion. The stabilizer 14is positioned closer to the distal tip 44 of the device. The tip 44 mustfirst cross the valve and open the stabilizer 14 to position the device,hold certain portions of the leaflets and counteract the impact.

Reference is now made to FIG. 14 and FIG. 15 , which illustrate anembodiment of an impactor catheter based on a pneumatic energy source onthe proximal side of the catheter and a weight-pull impact mechanism onthe distal portion. Again, similar elements are similarly designated asabove.

Reference is now made to FIG. 14 , which illustrates the distal end ofthe catheter. The catheter is delivered over guide wire 11 into thevalve. The external sheath (shaft) 12 is retracted to expose stabilizerarms 50 which expand outwards from external shaft 12. (Stabilizer arms50 extend from a stabilizer shaft 51 shown in FIG. 15 .) The catheter isthen pushed distally until stabilizer arms 50 make sufficient contactwith the aortic aspect of the valve leaflets. The impactor is thenadvanced through the center of the valve (over guide wire 11) into theLVOT (Left Ventricular Outflow Tract).

This embodiment includes impactor arms 52, which are preferably, but notnecessarily, cut out of a nitinol tube and are pre-shaped to be normallyhalf-open. The distal ends (or one common distal end) of the impactorarms 52 are/is fixed (e.g., welded) to an internal tube (shaft) 54 whichis free to move back and forth inside the impactor tube (shaft) 18. Whenthe internal tube 54 is pulled proximally by the operator on theproximal side of the catheter, the impactor arms 52 extend outwardssideways, increasing the impactor diameter. When the internal tube 54 ispushed distally, the impactor arms 52 close or decrease their diameter.Varying the relative position of the internal tube 54 relative toimpactor shaft 18 allows the operator to set the optimal impactordiameter per treated valve during the procedure. Furthermore, it allowsthe operator to select the regions on the calcified leaflets, which areimpacted. Another option shown in this embodiment is the capability torotate the impactor vis-à-vis the stabilizer (or together with thestabilizer) and the valve leaflets, in order to impact yet additional(or different) regions on the valve leaflets. Upon setting the impactorarms diameter and angular position, these settings can be now locked bythe user (by locking the position of the internal tube 54 at the controlside of the catheter in the hands of the operator). The impactor is nowpulled gently until it makes sufficient contact with the ventricularside of the leaflets and is now locked in longitudinal position as well.

Weight 24 can be pulled proximally as described above by means of aweight pull shaft 56.

Reference is now made to FIG. 15 , which illustrates the proximal sideof the impactor catheter described in FIG. 14 . A pneumatic energysource 58 (which serves as the biasing device) is connected to apressurized air source 60 (operating room wall inlet, compressor,balloon etc.). The body of the pneumatic energy source 58 is preferablyconnected to the stabilizer shaft 51, in order to counteract the impactapplied to the valve leaflets on the distal portion of the catheter. Thelongitudinal position of the internal shaft 54 with respect to theimpactor shaft 18, as well as the longitudinal and angular position ofthe impactor shaft 18, are set and locked by the user as described inFIG. 14 . The weight / pull shaft 56 is now pushed to the most distalposition and then connected to a piston 62 and proximal mass 64. Piston62 is arranged to slide in a main cylinder 66, which houses a pneumaticvalve 68 and which is open to air flow from an air container 70 via anair inlet 72. When pneumatic valve 68 is opened by the operator, thepressurized air in air container 70 is released through air inlet 72into main cylinder 66, thereby accelerating piston 62 and proximal mass64 rapidly over a certain distance. Piston 62 and proximal mass 64 gainrelatively high energy (momentum) while pulling the weight / pull shaft56 that are connected to the distal weight 24 at the tip of thecatheter. Upon reaching a certain travel distance, the distal weight 24hits the impactor arms 52, which then transfers the energy to the valvecalcification to produce fractures. Using the weight / pull mechanismallows to transfer high impact energy over a flexible catheter.

Reference is now made to FIGS. 16A-16D, which illustrate an impactordevice 100, in accordance with another non-limiting embodiment of thepresent invention. Device 100 includes an outer sheath 101 in which aredisposed one or more locating elements 102 and one or more (radially)vibratory (impacting) elements 103. Device 100 has a tip 104 whichallows it to be guided through the vasculature over guidewire 11. FIGS.16A through 16D show the gradual withdrawal of outer sheath 101 and theopening of the locating elements 102. FIG. 16D shows the radial openingof vibratory elements 103.

The vibratory mechanism is an active device which can be made to movein-and-out in the radial direction with a frequency and amplitude thatis determined by the operator, or comes preset by the manufacturer. Theinner vibratory mechanism proceeds to vibrate against the inside of thenative leaflet, applying force at a specified location, while thelocating elements having been positioned earlier, and provide resistanceto said force. The resulting action can remodel the calcificationstructure within the leaflet.

The vibratory mechanism can be constructed as a tube having slits cutaxially around its circumference. Should the tube be compressed suchthat its ends move one towards the other, the material between thecircumferentially cut slits would extend radially outward (elements103).

Reference is now made to FIG. 17 , which illustrates the distal end ofdevice 100 with both locating and vibratory elements 102 and 103 intheir open positions, respectively. It is noted that vibratory elements103 may be distributed equally or unequally around the circumference ofthe device 100.

FIGS. 18A and 18B illustrate a diseased tricuspid heart valve withdiseased leaflets having calcified lesions. The opening of the valve(FIG. 18B) is adversely affected by the calcification.

Reference is now made to FIGS. 19A-19I, which illustrate the treatmentof the diseased valve using the device. Guidewire 11 is introduced intothe artery and advanced until its distal end passes through the valveleaflets. In the case of the aortic valve, the guidewire 11 would beadvanced until its distal end is located within the left ventricle. Thedevice 100 is advanced over the guidewire 11 until its distal end islocated at or near the valve annulus. Outer sheath 101 is withdrawnpartially, exposing the locating mechanism whose elements 102 extendradially outward. The device 100 is moved in a distal direction (towardsthe left ventricle in the case of the aortic valve) so that locatingelements 102 rest against the pocket between the downstream surface ofthe leaflets and the arterial wall. The device 100 can be rotated gentlyin order to facilitate the proper positioning of the elements 102.

Once in place, the vibrating mechanism is actively expanded radially sothat vibratory elements 103 rest against the inside or upstream surfaceof the valve leaflets. Pre-tensioning the vibrating elements 103 againstthe leaflets is possible, such that tension is maintained against theleaflet tissue which is sandwiched between the locating elements 102 andthe vibrating elements 103.

The operator can now begin the vibratory motion of elements 103 so thata repetitive force is applied to the inner surface of the leaflets, thusaffecting a change in the structure of the calcific buildup within theleaflet tissue.

Reference is now made to FIG. 20 , which illustrates the locatingelements 102 having a mesh 105 connected to them so as to capture anydebris that may be created as part of the process. The mesh can bedistributed around the locating elements 102, and can be made out of awide range of suitable materials.

Reference is now made to FIGS. 21A and 21B, which illustrate anotherpossible embodiment wherein the locating elements 102 are inflatablecushions or balloons. The balloons are often filled with a liquid suchas saline, and can offer the counter force needed in order to resist theforce generated by the vibratory mechanism. The balloons are inflated insuch a way as not to block the coronary ostia.

FIG. 22A illustrates a longitudinal cut through the aortic wall withfracture lines created at the centerline of each leaflet by an impactor(which, for example, has three impacting arms). Similarly any number andpattern of fractures can be pre-set or achieved. FIG. 22B is an x-ray ofa typical leaflet after a single fracture was created close to itscenterline.

The scope of the present invention includes both combinations andsubcombinations of the features described hereinabove as well asmodifications and variations thereof which would occur to a person ofskill in the art upon reading the foregoing description and which arenot in the prior art.

What is claimed is:
 1. A method for heart valve treatment comprising:providing a first heart valve treatment member movable along a firstshaft portion; providing a second heart valve treatment member movablealong a second shaft portion, wherein said first and second heart valvetreatment members are movable along said first and second shaftportions, respectively; causing said first heart valve treatment memberto be positioned on one side of a heart valve leaflet and causing saidsecond heart valve treatment member to be positioned on an opposite sideof the heart valve leaflet; and fracturing a portion of the heart valveleaflet by movement of said first heart valve treatment member withrespect to said second heart valve treatment member.
 2. The methodaccording to claim 1, wherein fracturing the portion of the heart valveleaflet comprises cutting the portion of the heart valve leaflet.
 3. Themethod according to claim 1, wherein fracturing the portion of the heartvalve leaflet comprises chopping the portion of the heart valve leaflet.4. The method according to claim 1, wherein fracturing the portion ofthe heart valve leaflet comprises dividing the heart valve leaflet intotwo portions.
 5. The method according to claim 1, wherein fracturing theportion of the heart valve leaflet is part of a trans-catheter valveimplantation procedure.